CurrentCignaPolicy 0551

Anesthesia Services for Interventional Pain Management Procedures in an Adult - (0551)

Defines diagnoses (ICD-10-CM codes) and general background about anesthesia levels and monitored anesthesia care (MAC) related to interventional pain management procedures in adults; lists many specific ICD-10 codes that are not covered/reimbursable in the policy part shown and provides clinical background on sedation levels and MAC roles.

Policy Summary

PayerCigna

PolicyAnesthesia Services for Interventional Pain Management Procedures in an Adult - (0551)

Policy CodePolicy 0551

Change TypeRevised policy statement (Annual Review 2/15/2026)

Effective DateFeb 15, 2026

Next Review DateFeb 15, 2027

Key ActionObtain anesthesiology consultation or involve an anesthesia practitioner (MAC) when patient comorbidities, ASA III-IV status, advanced age, severe cardiopulmonary disease, obesity (BMI>40), obstructive sleep apnea, significant hepatic/renal impairment, airway abnormalities, or procedure requirements exceed the expertise/resources of non-anesthesia personnel.

SourceLink

POLICY UPDATE CHANGES

Revised policy statement for interventional pain procedures for moderate sedation and monitored anesthesia care.

No clinical policy statement changes during focused review on 10/15/2025.

No clinical policy statement changes during annual reviews dated 2/15/2025 and 2/15/2024.

ExtensiveICD-10 codes listed

1Policy part number (of 3)

2026-02-15

Coverage summary

This policy (Medical Coverage Policy Number 0551, effective 2026-02-15) addresses anesthesia services for interventional pain management procedures in adults and defines criteria for moderate sedation and monitored anesthesia care (MAC). It also specifies an extensive list of ICD-10-CM diagnosis codes (Table 4) that are designated as Not Covered or Reimbursable for these services. The policy applies to interventional pain procedures such as trigger point injections, epidural steroid injections, epidural blood patches, facet joint injections, nerve blocks, neurolytic blocks, radiofrequency ablation, and implantation of spinal cord stimulators or intrathecal infusion devices, and references Medicare LCDs relevant to MAC and pain management (e.g., L35049, L33622).

Not Covered / Reimbursable Diagnoses (Table 4)

ICD-10-CM diagnosis codes listed as Not Covered or Reimbursable (Table 4 entries)ICD-10Not Covered

F02.C11	Dementia in other diseases classified elsewhere, severe, with agitation
F02.C18	Dementia in other diseases classified elsewhere, severe, with other behavioral disturbance
F02.C2	Dementia in other diseases classified elsewhere, severe, with psychotic disturbance
F02.C3	Dementia in other diseases classified elsewhere, severe, with mood disturbance
F02.C4	Dementia in other diseases classified elsewhere, severe, with anxiety
F06.0	Psychotic disorder with hallucinations due to known physiological condition
F06.2	Psychotic disorder with delusions due to known physiological condition
F06.70	Mild neurocognitive disorder due to known physiological condition without behavioral disturbance
F06.71	Mild neurocognitive disorder due to known physiological condition with behavioral disturbance
F10.10	Alcohol abuse, uncomplicated

1–10 of 450

1/45

Medical-necessity criteria for sedation and Monitored Anesthesia Care (MAC)

Provider actions and documentation requirements

Documentation Required

Use of MAC and sedation level documentation

When monitored anesthesia care (MAC) or deeper sedation is provided, document the anesthesia practitioner's role, preprocedural assessment, intra-procedural monitoring and interventions, and readiness to convert to general anesthesia as required by ASA definitions.

Prior Authorization

Consultation/Anesthesia involvement when risk factors present

Obtain anesthesiology consultation or involve an anesthesia practitioner (MAC) when patient comorbidities, ASA III-IV status, advanced age, severe cardiopulmonary disease, obesity (BMI>40), obstructive sleep apnea, significant hepatic/renal impairment, airway abnormalities, or procedure requirements exceed the expertise/resources of non-anesthesia personnel.

Background, definitions, and evidence

Interventional pain procedures are invasive interventions to manage acute or chronic pain and include injections, nerve blocks, neurolytic procedures, radiofrequency ablation, and device implantation. Most are performed with local anesthesia and typically do not require supplemental sedation; when sedation is used, it is most often minimal or moderate (conscious) sedation administered by the performing physician. The American Society of Anesthesiologists (ASA) defines levels of sedation (minimal, moderate, deep, general), and characterizes moderate sedation as a drug-induced depression of consciousness in which patients respond purposefully to verbal commands, airway intervention is not required, and cardiovascular function is usually maintained. Monitored Anesthesia Care (MAC) is a distinct anesthesia practitioner service for diagnostic or therapeutic procedures that may include varying levels of sedation; the anesthesia professional focuses on airway, hemodynamic, and physiologic stability, provides preprocedural assessment and intra-procedural management, and must be prepared to convert to general anesthesia if necessary. Deep sedation and general anesthesia are generally contraindicated for most interventional pain procedures because they prevent patient reporting of pain or sensory changes that may indicate procedural complications.

Moderate sedation/analgesia (conscious sedation): ASA-defined drug-induced depression of consciousness during which patients respond purposefully to verbal commands, no interventions are required to maintain a patent airway, spontaneous ventilation is adequate, and cardiovascular function is usually maintained. (ASA definition referenced in policy.)

Monitored Anesthesia Care (MAC): A service rendered by an anesthesia practitioner not involved in the diagnostic/procedural service; MAC may include varying levels of sedation, analgesia, and anxiolysis, and the anesthesia professional focuses on airway, hemodynamic, and physiologic stability, provides preprocedural assessment and peri-procedural diagnosis/treatment/support of vital functions, administers sedatives/analgesics/anesthetic agents as necessary, offers psychological support, and is prepared to convert to general anesthesia if needed. (ASA definitions and service elements cited in policy.)

Coding and referenced Medicare determinations

Medicare Determinations referencedmixed

L35049	Monitored Anesthesia Care (LCD), Novitas Solutions, Inc., Revision Effective Date 10/17/2019
L33622	Pain Management - Injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels (LCD), National Government Services, Inc., Revision Effective Date 4/1/2024

Determination name	Number	Type	Effective
{"text":"Epidural Steroid Injections for Pain Management","status":""},{"text":"","status":""},{"text":"LCD","status":""},{"text":"Varies","status":""}
{"text":"Facet Joint Interventions for Pain Management","status":""},{"text":"","status":""},{"text":"LCD","status":""},{"text":"Varies","status":""}
{"text":"Sacroiliac Joint Injections and Procedures","status":""},{"text":"","status":""},{"text":"LCD","status":""},{"text":"Varies","status":""}
{"text":"Pain Management - Injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels","status":""},{"text":"L33622","status":""},{"text":"LCD","status":""},{"text":"2024-04-01","status":""}
{"text":"Monitored Anesthesia Care","status":""},{"text":"L35049","status":""},{"text":"LCD","status":""},{"text":"2019-10-17","status":""}
{"text":"No Determination found","status":""},{"text":"","status":""},{"text":"NCD","status":""},{"text":"","status":""}

Revision history

2026-02-15annual_reviewLatest

Annual Review — Revised policy statement for interventional pain procedures for moderate sedation and monitored anesthesia care (policy statement revised).

2025-10-15focused_review

Focused Review — No clinical policy statement changes.

2025-02-15annual_review

Annual Review — No clinical policy statement changes.

Source	Key point
ASA statement (2021/2023/2024)
Interventional pain procedures generally do not require sedation; MAC is a distinct anesthesia service focused on airway/hemodynamic management and readiness to convert to general anesthesia.
ACR/SIR (2025 practice parameter)
ASA I-II appropriate for minimal/moderate sedation by non-anesthesia personnel; anesthesiology consultation recommended when medical history/comorbidities/sedation goals exceed non-anesthesiology capabilities.
ESRA guideline (2018)
Lists comorbidities where anesthesiologist evaluation/management is required (eg, severe cardiovascular disease, OSA, morbid obesity, chronic renal failure, chronic liver disease, age>70, ASA III-IV, airway abnormalities).